New York Hospital Research Articles

Management and outcomes of proteasome inhibitor associated chalazia and blepharitis: a case series

BackgroundThe purpose of this case series was to further characterize proteasome inhibitor associated chalazia and blepharitis, to investigate outcomes of different management strategies, and to propose a treatment algorithm for eyelid complications in this patient population.MethodsThis retrospective case series included sixteen patients found to have chalazia and/or blepharitis while receiving proteasome inhibitors for plasma cell disorders at Mount Sinai Hospital in New York, NY from January 2010 through January 2017. Main outcomes were complete resolution of eyelid complications and time to resolution. Student’s t-test was used to compare average values and Fisher’s exact test was used to compare proportions.ResultsFourteen patients had chalazia and 10 had blepharitis. Chalazia averaged 5.4 mm, and 11 patients with chalazia experienced two or more lesions. Median follow-up time was 17 months. Average time from bortezomib exposure to onset of first eyelid complication was 3.4 months. Chalazia episodes were more likely to completely resolve than blepharitis episodes (p = 0.03). Ocular therapy alone was trialed for an average of 1.8 months before proceeding to bortezomib omission. Average time to eyelid complication resolution using ocular therapy alone was 1.8 months versus 3.1 months after bortezomib omission. In this series, the combination of ocular therapy and bortezomib omission led to complete resolution of eyelid complications more often than ocular therapy alone.ConclusionProteasome inhibitor associated eyelid complications were identified in sixteen patients with plasma cell disorders. Eyelid complications may be treated with a 2-month trial of conservative ocular therapies alone, followed by continuation of ocular therapy in combination with bortezomib omission if eyelid signs persist.

Vladimir Horowitz (1903-1989).

Back to table of contents Previous article Next article Images in PsychiatryFull AccessVladimir Horowitz (1903–1989)Anne R. Hart, M.D., Charles H. Kellner, M.D.Anne R. HartSearch for more papers by this author, M.D., Charles H. KellnerSearch for more papers by this author, M.D.Published Online:1 May 2019https://doi.org/10.1176/appi.ajp.2018.18060672AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Among the many celebrities who have been treated with electroconvulsive therapy (ECT), Vladimir Horowitz stands out as the preeminent musician. Widely celebrated as the foremost concert pianist of the 20th century, Horowitz was a champion of the romantic repertoire, and he reimagined concepts of tone, color, and expression. Privately, however, he had a complicated psychiatric history. He had multiple phobias, paralyzing performance anxiety (which he tried to mitigate by bringing his own piano to every concert), and severe bouts of depression throughout his life. His most debilitating episodes of depression lasted for years on end and were so severe that he withdrew from playing the piano entirely. What is less widely known is that he was successfully treated with ECT on multiple occasions.Concert pianist Vladimir Horowitz in Amsterdam, 1986. (By Roland Gerrits/Anefo. Image from the Nationaal Archief, the Dutch National Archives, and Spaarnestad Photo, donated in the context of a partnership program. Image file licensed under the Creative Commons Attribution-Share Alike 3.0 Netherlands license.)Horowitz was born in Kiev in 1903, the youngest of four children in a Jewish family. His talents as a young pianist brought him to the West in 1925, where he lived for the rest of his life. He married Wanda Toscanini, the daughter of his mentor, conductor Arturo Toscanini, and they had one daughter, Sonia.His first episode of depression began in 1933, during which he retreated to Lucerne, Switzerland, for 2 years, away from public performance. During this time, he grappled with crippling low self-esteem about his musicianship and perhaps his sexuality as well. His psychoanalysis with Lawrence Kubie in the 1940s may have been, at least in part, an effort to alter his sexual orientation.His second and most severe episode of major depression started in 1953 and resulted in a 12-year retirement from the concert stage. This period was marked by the death of his father-in-law and a traumatic brain injury to his daughter Sonia. He received ECT in 1963 at Presbyterian Hospital in New York, which enabled him to return to his performance career. According to one of his biographers, Horowitz described ECT as a “wonderful treatment that healed his nerves” (1).His third and final depressive episode occurred in 1983, precipitated by a concert tour that was poorly reviewed by friends and critics alike, with the New York Times reporting “lots of wrong notes, clotted chords, and rhythmic distortions. The famous Horowitz precision was only intermittently in evidence” (2). His depression led to physical debility. Historical records hint that he may have had problems with overuse of prescribed barbiturates as well. Another course of ECT, at the Neurological Institute in New York City, resulted in complete recovery. He was subsequently able to perform in Russia for the first time in 61 years, for what would become his final, triumphant international tour. The New York Times raved, “Horowitz returned to the Soviet musical stage today, giving a recital that dazzled the audience and left many in tears.… The audience, applauding loudly and shouting cheers, brought Mr. Horowitz back on stage for six curtain calls after he had played three encores” (3).Horowitz died in 1989 in New York City and is buried in the Toscanini mausoleum in Milan.Icahn School of Medicine at Mount Sinai, New York; and New York Community Hospital, Brooklyn.Send correspondence to Dr. Kellner ([email protected]).References1 Plaskin G: Horowitz: A Biography of Vladimir Horowitz. New York, William Morrow & Co, 1983Google Scholar2 Schonberg HC: Horowitz: His Life and Music. New York, Simon & Schuster, 1992Google Scholar3 Taubman P: For Horowitz in Moscow, bravo and tears. New York Times, April 21, 1986Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 176Issue 5 May 01, 2019Pages 341-341 Metrics KeywordsECTHistory Of PsychiatryCreativityMood Disorders-UnipolarPDF download History Accepted 24 September 2018 Published online 1 May 2019 Published in print 1 May 2019

Time to Therapeutic Tacrolimus Serum Concentrations and the Impact on Early Acute Cellular Rejection in Adult Lung Transplant Recipients

Purpose Acute cellular rejection (ACR) affects up to 55% of lung transplant recipients (LTR) within the first year post-transplant. Maintenance immunosuppression regimens include calcineurin inhibitors, antimetabolites, and corticosteroids. Previous studies have shown that early ACR can lead to more severe rejection episodes within the first year post-transplant. The aim of this study is to evaluate the relationship between the time to therapeutic tacrolimus trough concentrations immediately after lung transplant and early clinical ACR post lung transplant. Methods This was a single center, retrospective cohort study of 208 adult LTR transplanted between March 1, 2012 and December 31, 2015 at NewYork-Presbyterian Hospital, Columbia University Irving Medical Center. Recipients were stratified into four groups based on the time to therapeutic tacrolimus concentrations: 0-7, 8-14, 15-29, and ≥30 days post-transplant. Therapeutic tacrolimus trough concentrations were defined as two consecutive levels between 10-15 ng/mL. The primary outcome was the incidence of clinical ACR 6 weeks post-transplant. Clinical ACR included both biopsy proven rejection and treated rejection. Secondary outcomes included biopsy proven ACR 4 and 12 weeks post-transplant and the incidence of acute kidney injury 7, 14, and 30 days post-transplant. Multivariable logistic regression was performed to assess the primary outcome with adjustment for donor age, recipient age, recipient sex, primary graft dysfunction (PGD) within 72 hours post-transplant, and pre-transplant HLA sensitization. Results The incidence of clinical ACR within 6 weeks post-transplant did not differ between groups: 68%, 66%, 71%, and 71% in the 0-7, 8-14, 15-29, and ≥30 days post-transplant groups, respectively (p=0.94). No differences were seen in adjusted and unadjusted analysis. No difference was found in the incidence of AKI within 7 (p=0.25) or 30 (p=0.32) days post-transplant. The incidence of AKI within 14 days was higher in the 15-29 day group (26%), compared to 7%, 14%, 7% in groups 0-7, 8-14, and ≥30 days, respectively (p=0.05). Conclusion There was no difference in the incidence of early clinical ACR among adult LTR who achieved therapeutic tacrolimus trough concentrations 0-7, 8-14, 15-29, or ≥30 days post-transplant.

Abdominal Aortic Aneurysm Repair Readmissions and Disparities of Socioeconomic Status: A Multistate Analysis, 2007-2014

To determine differences in perioperative abdominal aortic aneurysm (AAA) repair outcomes based on patient sociodemographics. A retrospective analysis of patient hospitalization and discharge records. All-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California. A total of 92,028 patients from the State Inpatient Databases Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality from January 2007 to December 2014 (excluding California, ending December 2011) who underwent AAA repair. Data extraction and univariate and multivariate regression analysis. Patients in the highest income quartile were less likely to be readmitted compared with those in the poorest income quartile at both 30 days (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.83-0.95) and 90 days (OR 0.85, 95% CI 0.81-0.91). Hospital readmissions were significantly greater for African American (OR 1.32, 95% CI 1.20-1.44) and Hispanic patients (OR 1.14, 95% CI 1.04-1.25) compared with white patients 30 days after AAA repair. These results were consistent 90 days after AAA repair. Patients insured with Medicare (OR 1.25, 95% CI 1.17-1.34) or Medicaid (OR 1.46, 95% CI 1.30-1.64) were more likely to be readmitted after both time points as compared with those with private insurance. The authors also found that patients with lower income, African American and Hispanic patients, and patients without private insurance were all significantly more likely to undergo emergency rather than elective repair. Lower socioeconomic status is shown to be an independent risk factor for increased postoperative morbidity in AAA repair. The authors believe the present study demonstrates the importance of socioeconomic status as a factor in perioperative risk stratification.

Characterising variation in composition and activation criteria of rapid response and cardiac arrest teams: a survey of Medicare participating hospitals in five American states

ObjectivesTo characterise the variation in composition, leadership, and activation criteria of rapid response and cardiac arrest teams in five north-eastern states of the USA.DesignCross-sectional study consisting of a voluntary 46-question...

Patients' Perception of Stressful Events in the Intensive Care Unit After Cardiac Surgery.

Subjecting patients to stress has potentially detrimental effects on their physical and psychological recovery. To identify stress-generating experiences that occur in an intensive care unit for patients after cardiac surgery. A sample of 16 patients in a 14-bed cardiovascular intensive care unit at a university hospital in upstate New York completed a questionnaire (based on an established survey) asking them to rate 23 experiences on a Likert scale of 0 to 4. All patients were adults and had undergone coronary artery bypass graft surgery. After surgery, they were extubated and completed the questionnaire within 12 to 24 hours. Patients reported pain to be the most stressful experience, followed by presence of an endotracheal tube and sleeplessness. With pain, endotracheal intubation, and sleeplessness identified as highly distressing to patients, further research can be done to elicit interventions that could alleviate some of the stress involved with a postoperative stay in an intensive care unit.

The Trend, Feasibility, and Safety of Salpingectomy as a form of Permanent Sterilization

To assess the change in the rate of laparoscopic salpingectomy for sterilization after the release of the November 2013 Society of Gynecologic Oncology Clinical Practice Statement and the January 2015 American College of Obstetricians and Gynecologists Committee Opinion: Salpingectomy for Ovarian Cancer Prevention. We hypothesized there would be an increase in salpingectomy as a percentage of total laparoscopic sterilizations performed without an increase in complications when compared with conventional bilateral tubal ligation (BTL). A retrospective cohort study. Four university-affiliated hospitals in Houston, TX, and New York, NY. All women 21 years or older who underwent interval laparoscopic permanent sterilization between April 2013 and September 2016. Sterilization by bilateral salpingectomy or conventional tubal ligation. There were 454 sterilization procedures identified; 60% were BTLs, whereas 40% were salpingectomies. The rate of use of salpingectomy significantly increased from 5% to 9% in 2013 to 2014 to 78% by 2016. There was no significant difference in intraoperative or postoperative complications or estimated blood loss. The mean procedure time was 54 minutes for salpingectomy compared with 45 minutes for BTL (p <.0001). Salpingectomy was more likely to require 3 ports compared with 2 ports for BTL (p <.0001). The Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists' support of salpingectomy for ovarian cancer prevention increased its use for sterilization. Based on this study, laparoscopic bilateral salpingectomy is a safe method of sterilization without an increase in perioperative risk compared with conventional tubal ligation. Physicians should incorporate these findings and implications when counseling patients regarding contraception and permanent sterilization.

Abstract TP533: Decreasing Treatments for Subarachnoid Hemorrhage at Highest Volume Centers: A 10-Year Cohort Study

Introduction: With increasing availability of endovascular aneurysm treatments away from tertiary referral centers, greater numbers of patients with aneurysmal subarachnoid hemorrhage (SAH) may be treated at lower-volume centers. This trend over time as well as its influence on patient outcomes remains poorly characterized. Methods: Using administrative data on all discharges from hospitals in New York (2005-2014) and Florida (2005-2015), we identified patients with treated aneurysmal SAH. Primary outcome was in-hospital mortality. Patients with trauma were excluded. Logistic regression adjusted for comorbidities was used to assess the relationship of hospital volume on outcome. Results are provided as median [IQR], mean ± SD and OR [95% CI]. Results: Among 12,290 patients with aneurysmal SAH, 69% were female and median age was 55 [46 - 65]. 62% were treated with endovascular coiling (EC) and 37% with surgical clipping (SC). Over the time span of the study, the number of hospitals treating SAH did not increase (88 vs. 71, 2005 vs. 2014), nor did the number of patients with SAH (1159 vs. 1212, 2005 vs. 2014). Hospitals that treated fewer numbers of patients with SAH annually were more likely to perform SC than EC (51% vs. 40%, 1-10 vs. ≥ 40 annual SAH treatments, p&lt;0.001). Over the course of the study, mean annual SAH treatments per hospital decreased (38 ± 23 vs 34 ± 18, 2005 vs. 2014, p&lt;0.0001) with fewer SAHs treated at the highest volume centers and increasing numbers at intermediate volume centers (Figure). In adjusted logistic regression, the likelihood of in-hospital mortality decreased with increasing annual SAH treatment volume (-3.3% per 10 SAH admissions/year, p&lt;0.05). Conclusion: In this 10-year observational cohort, lower volume hospitals were more likely to perform SC, and fewer SAH patients were treated at the highest volume centers over time. These findings corroborate a de-centralization of SAH care, which may be associated with worse outcomes.

Abstract 65: Risk of Intracerebral Hemorrhage Associated With Pregnancy in Women With Cerebral Arteriovenous Malformations: A Large-Scale Controlled Cohort Study

Introduction: Prior single-center reports have suggested an increased incidence of intracerebral hemorrhage (ICH) from cerebral arteriovenous malformation (AVM) rupture during pregnancy. Unfortunately, data on this topic are limited due to small sample size as well as the aggregation of all patients with AVMs, failing to account for the well-described variability in ICH risk based on AVM size, location and morphology. Methods: Using administrative data on all discharges from hospitals in New York (2005-2014) and Florida (2005-2015), we identified patients with first time pregnancy and delivery. The primary endpoint was first time ICH. We used a case-crossover design in which each woman and her unique AVM served as her own control, by matching the pregnancy period with an equal duration of time 1 year prior. Women were excluded for any treatment (embolization, surgery or radiosurgery) for AVM or first time ICH prior to the control period. Results are presented as OR [95% CI] or median [IQR]. Results: Among 6,273,562 women with first time pregnancy, median age was 28 [23 – 33], 49% were white, 19% were black, and 19% were Hispanic. Of these patients, 1,024 (0.02%) had an AVM and 79 were excluded for ICH or treatment prior to the control period. Women with AVMs were more likely to undergo Caesarian section than those without (58% vs. 36%, p&lt;0.001). There were no major differences in vascular risk factors between the women without an AVM versus those with AVM. In unmatched analysis, the incidence of first time ICH in women with AVMs was greater than those without in the control (0.8% vs. 0.001%, p&lt;0.0001), pregnancy/delivery (5.1% vs. 0.01%, p&lt;0.0001), and 12-week post-partum (1.2% vs 0.01%, p&lt;0.0001) periods. In matched case-crossover analysis in women with AVMs, pregnancy was associated with an increased risk (OR 3.4 [1.4 – 8.6]) relative to the control non-pregnant period. Conclusion: In this large-scale cohort study in which women with AVMs served as their own controls, we account for the variability in ICH risk based on AVM morphology and identify a nearly 350% increased risk of ICH associated with first time pregnancy and delivery. These findings support the need for further work on mechanistic underpinnings as well as a major need for improved methods to abrogate ICH risk.

Abstract TP189: Diagnosis and Treatment Trends of Cerebral Venous Thrombosis in a Large Observational Cohort

Background: Cerebral Venous Thrombosis (CVT) is an increasingly recognized etiology of a wide array of neurological presentations ranging from headache to coma with limited treatment options. Here, we review population-level trends in the diagnosis, treatment and outcomes of CVT. Methods: Using administrative data on all discharges from hospitals in New York (2005-2014) and Florida (2005-2015), we identified patients with CVT. Patients with trauma and pyogenic CVT were excluded. Primary outcomes included hospital length of stay and discharge disposition. Linear and logistic regressions were adjusted for age, sex, year of treatment, and hypercoagulability. Results are provided as median [IQR], mean ± SD and OR [95% CI]. Results: Among 1876 patients diagnosed with CVT, median age was 59 [42 - 73] and 60% were female. 61% of the cohort was white, 17% African American and 13% Hispanic. Hypertension was present in 53%, diabetes in 21%, 18% smoked and 4% were diagnosed with a hypercoagulable disorder. 230 (12%) of patients presented with intracerebral hemorrhage. Over the 10-year span of the study, the number of patients diagnosed with CVT annually increased (136 vs. 227, 2005 vs. 2014). 81 (4.3%) of patient were treated with endovascular thrombectomy and/or thrombolysis. This proportion increased significantly over the course of the study (1% vs. 5%, 2005 vs. 2014, p&lt;0.05). In adjusted logistic regression, the likelihood of discharge home versus in-hospital mortality/SNF did not change over the course of the study period (p=0.8). In the subset of patients presenting with intracranial hemorrhage, thrombectomy was associated with increased length of stay (eta 2 0.02, p&lt;0.05, adjusted linear regression), but there was no effect on likelihood of discharge home (p=0.5) or in-hospital mortality/discharge to SNF (p=0.4). Conclusions: In this large observational cohort study over 10-years, we identify an increasing frequency of diagnosis of CVT, without notable changes in discharge outcomes. These findings support the need for further targeted therapies for patients with CVT.

Abstract 45: Treatment Trends and Clinical Outcomes for Unruptured Cerebral Aneurysms in High vs Low Volume Centers

Background: Prior studies have suggested that unruptured cerebral aneurysm (CA) treatments have spread from high-volume centers into lower-volume centers in the past decade, coinciding with the increase of endovascular coiling (EC) relative to surgical clipping (SC). Our understanding of outcomes from CA treatments by hospital treatment volumes is lacking. Methods: Using administrative data on all discharges from hospitals in New York (2005-2014) and Florida (2005-2015), we identified patients with treatments for unruptured CAs. Good outcome was defined as discharge home without intracerebral hemorrhage (ICH) and poor outcome as discharge to SNF or death. A composite weighted index of risk factors was calculated using the Charlson Comorbidity Index (CCI). Logistic regression adjusted for age, sex, smoking, diabetes and CCI were performed. Results are provided as median [IQR] or OR [95% CI]. Results: Among 14,064 patients with treated unruptured CAs, median age was 58 [49 - 66] and 75% were female. EC was performed in 9,417 (67%), and increased over time (56% vs. 74%, 2006 vs. 2014). Annual treatments increased over the study period, with 1125 CAs treated in 2006 versus 1517 in 2014, whereas the number of treating hospitals did not (66 vs. 64, 2006 vs. 2014). In adjusted logistic regression, there was no difference in likelihood of a good outcome over time (OR 0.94 [0.86 - 1.03], 2012-2015 vs. 2005 - 2008). The likelihood of good outcome increased with annual hospital treatment volume ( Figure 1a ). This relationship was maintained for patients treated with SC and EC (ORs 1.7 [1.33 - 2.2] and 3.2 [2.5 -4.1]). The likelihood of poor outcome conversely decreased consistently with increasing annual treatment volume ( Figure 1b ). Conclusion: In this large cohort study, we did not observe an increase in the number of hospitals performing CA treatments. However, for patients treated with both SC and EC, treatment at higher-volume centers was associated with improved outcomes.

Characteristics of Urban Inpatient Smokers With and Without Chronic Pain: Foundations for Targeted Cessation Programs

Background: Cigarette smoking and chronic pain are prevalent, comorbid conditions with significant consequences for individuals and society. Despite overlap between smoking and chronic pain, and pain’s role as a potential barrier to quitting, there are no validated interventions targeted for smokers with chronic pains (SWCPs). Objective: To compare characteristics of urban inpatient smokers with and without chronic pain to inform the development of SWCP-targeted cessation interventions. Methods: This study reports partial results from a randomized comparative effectiveness trial of two smoking cessation interventions (NCT01363245). Participants were enrolled at two safety net hospitals in New York, NY in 2011–2014. Data were collected from the electronic health record and an interviewer-administered survey. Participants were considered to have chronic pain if they affirmed having “long-lasting, persistent, or chronic pain in the last six months” on survey. Results: Among smokers assessed for pain (n = 1093), the prevalence of chronic pain was 44%. SWCPs were more likely to report depressive symptoms and to have a history of psychiatric diagnosis (nonsubstance related) than smokers without pain. Severe problems with mobility and with performing usual activities were more common in SWCPs. No significant difference was observed in sex, race, education, nicotine dependence level, confidence in quit ability, or history of substance misuse. Conclusions/Importance: Chronic pain in smokers admitted to safety net hospitals is prevalent and associated with hindered mobility, history of psychiatric diagnosis, and prescription opioid use. Urban safety net hospitals are an appropriate setting in which to pilot SWCP-targeted cessation programs, which should be designed with consideration for patients’ psychiatric history and mobility status.

Comparison of Risk-Standardized Readmission Rates of Surgical Patients at Safety-Net and Non–Safety-Net Hospitals Using Agency for Healthcare Research and Quality and American Hospital Association Data

Medical patients discharged from safety-net hospitals (SNHs) experience higher readmission rates compared with those discharged from non-SNHs. However, little is known about whether this association persists for surgical patients. To examine differences in readmission rates between SNHs and non-SNHs among surgical patients after discharge and determine whether hospital characteristics might account for some of the variation. This observational retrospective study linked the Healthcare Cost and Utilization Project State Inpatient Databases of the Agency for Healthcare Research and Quality from January 1, 2011, through December 31, 2014, for 4 states (New York, Florida, Iowa, and Washington) with data from the 2014 American Hospital Association annual survey. After identifying surgical discharges, SNHs were defined as those with the top quartile of inpatient stays paid by Medicaid or self-paid. Hospital-level risk-standardized readmission rates (RSRRs) for surgical discharges were calculated. The association between hospital RSRRs and hospital characteristics was evaluated with bivariate analyses. An estimated multivariable hierarchical linear regression model was used to examine variation in hospital RSRRs, adjusting for hospital characteristics, state, year, and SNH status. Data were analyzed from June 1, 2017, through March 1, 2018. Surgical care at an SNH. Readmission after an index surgical admission. A total of 1 252 505 patients across all 4 years and states were included in the analysis (51.7% women; mean [SD] age, 52.7 [18.1] years). Bivariate analyses found that SNHs had higher mean (SD) surgical RSRRs compared with non-SNHs; significant differences were found for New York (9.6 [0.1] vs 10.9 [0.1]; P < .001) and Florida (11.6 [0.1] vs 12.1 [0.1]; P = .001). The SNHs also had higher RSRRs in these 2 states when stratified by hospital funding (nonfederal government SNHs in New York, 11.9 [0.2]; for-profit, private SNHs in Florida, 13.1 [0.2]; P < .001 for both); however, bed size was a significant factor for higher mean (SD) RSRRs only for New York (200 to 399 beds, 12.0 [0.4]; P = .006). Similar results were found for multivariable linear regression models; RSRRs were 1.02% higher for SNHs compared with non-SNHs (95% CI, 0.75%-1.29%; P < .001). Increased RSRRs were observed for hospitals in New York and Florida, teaching hospitals, and investor-owned hospitals. Factors associated with reduced RSRRs included presence of an ambulatory surgery center, cardiac catheterization capabilities, and high surgical volume. According to results of this study, surgical patients treated at SNHs experienced slightly higher RSRRs compared with those treated at non-SNHs. This association persisted after adjusting for year, state, and hospital factors, including teaching status, hospital bed size, and hospital volume.

Electronic medical orders for life-sustaining treatment in New York State: Length of stay, direct costs in an ICU setting.

In the United States, approximately 20% patients die annually during a hospitalization with an intensive care unit (ICU) stay. Each year, critical care costs exceed $82 billion, accounting for 13% of all inpatient hospital costs. Treatment of sepsis is listed as the most expensive condition in US hospitals, costing more than $20 billion annually. Electronic Medical Orders for Life-Sustaining Treatment (eMOLST) is a standardized documentation process used in New York State to convey patients' wishes regarding cardiopulmonary resuscitation and other life-sustaining treatments. No study to date has looked at the effect of eMOLST as an advance care planning tool on ICU and hospital costs using estimates of direct costs. The objective of our study was to investigate whether signing of eMOLST results in any reduction in length of stay and direct costs for a community-based hospital in New York State. A retrospective chart review was conducted between July 2016 and July 2017. Primary outcome measures included length of hospital stay, ICU length of stay, total direct costs, and ICU costs. Inclusion criteria were patients ≥65 years of age and admitted into the ICU with a diagnosis of sepsis. An independent samples t test was used to test for significant differences between those who had or had not completed the eMOLST form. There were no statistical differences for patients who completed or did not complete the eMOLST form on hospital's total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU. Completing an eMOLST form did not have any effect on reducing total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.

No Association Between Pseudopolyps and Colorectal Neoplasia in Patients With Inflammatory Bowel Diseases

Background & Aims:Patients with inflammatory bowel diseases (IBD) who have post-inflammatory polyps (PIPs) have an increased risk of colorectal neoplasia (CRN). European guidelines propose that patients with PIPs receive more frequent surveillance colonoscopies, despite limited evidence of this increased risk. We aimed to define the risk of CRN and colectomy in patients with IBD and PIPs.Methods:We conducted a multicenter retrospective cohort study of patients with IBD who underwent colonoscopic surveillance for CRN, from January 1997 through January 2017, at 5 academic hospitals and 2 large non-academic hospitals in New York or the Netherlands. Eligible patients had confirmed colonic disease with duration of 8 years or more (or any duration, if they also have primary sclerosing cholangitis) and no prior history of advanced CRN (high-grade dysplasia or colorectal cancer) or colectomy. The primary outcome was occurrence of advanced CRN according to PIP status; secondary outcomes were occurrence of CRN (inclusive of low-grade dysplasia) and colectomy.Results:Among 1582 eligible patients, 462 patients (29.2%) had PIPs. PIPs were associated with more severe inflammation (adjusted odds ratio [aOR], 1.32; 95% CI, 1.13–1.55), greater disease extent (aOR 1.92; 95% CI, 1.34–2.74), and lower likelihood of primary sclerosing cholangitis (aOR 0.38; 95% CI, 0.26–0.55). During a median follow-up period of 4.8 years, the time until development of advanced CRN did not differ significantly between patients with vs without PIPs. PIPs did not independently increase risk of advanced CRN (adjusted hazard ratio, 1.17; 95% CI, 0.59–2.31). The colectomy rate was significantly higher in patients with PIPs (P=0.01).Conclusions:In a retrospective analysis of data from 2 large independent surveillance cohorts, PIPs were associated with greater severity and extent of colon inflammation and higher rates of colectomy, but were not associated with development of any degree of CRN. Therefore, intervals for surveillance should not be shortened solely based on the presence of PIPs.

1196. Serratia marcescens Strains Carrying blaKPC-2 and blaKPC-3 Carbapenemase Associated With Chronic Mechanical Ventilation

BackgroundCarbapenem resistance (CR) in Enterobacteriaceae is a growing concern which the CDC has designated as an urgent threat. At our institution we have noted emergence of CR strains in clinical isolates including a growing number of Serratia marcescens. CR in Serratia marcescens in the United States is mostly reported to be encoded by the SME family of chromosomally encoded carbapenemases, while in Asia it has been described being mediated by transmissible plasmids such as KPC. Here we describe the emergence and characteristics of CR Serratia marcescens at an academic tertiary care hospital in New York.Methods Serratia marcescens isolates demonstrating in vitro carbapenem resistance were recovered over a 12-month period from six distinct patients. Antibiotic resistance was determined by standard methods. Real-time PCR for bla(KPC), mcr gene, bla(NDM-1), bla(VIM), and bla(OXA-48) was performed. Patient comorbidities, source of culture, location in the hospital, and co-infection with other CR organisms were investigated.ResultsFourteen S. marcescens isolates demonstrating in vitro carbapenem resistance were recovered from six individual patients. All six patients had a history of chronic respiratory failure with tracheostomy and at least partial ventilator dependence. Five of the patients were located on the pulmonary intermediate care unit, and one in the pediatric intensive care unit. Twelve of the 14 isolates were tracheal or sputum cultures. Five of the sputum cultures from two patients were co-infected with CR Pseudomonas, and one sputum culture was simultaneously positive for CR Klebsiella pneumoniae and Enterobacter Cloacae. Nine out of 14 isolates were positive for blaKPC-3, two were blaKPC-2 positive, and three were blaKPC-negative, with no mechanism of carbapenem resistance determined yet. None of the other genes were detected.ConclusionMost carbapenem-resistant Serratia isolates were derived from respiratory tract and were found to be positive for blaKPC-3. This suggests that plasmid encoded carbapenemases are emerging among Serratia in the United States, which is already being reported in China. Genomic sequencing may establish whether this represents a clonal expansion and whether the blaKPC plasmid was transferred from Klebsiella or Enterobacter to Serratia in one of the patients.Disclosures All authors: No reported disclosures.

2439. Outcomes of Minocycline Use on Gram-Negative Infections and Implications of MIC

BackgroundMinocycline (MINO) is a treatment option for Acinetobacter baumannii and Stenotrophomonas maltophilia infections due to high in vitro susceptibility. Literature suggests it may also be an option for carbapenamase-producing enterobacteriaceae. MINO minimum inhibitory concentrations (MICs) vary by organism and dosing varies by center. Additional data are needed to assess MINO effectiveness in Gram-negative infections and determine if a relationship exists between MIC and treatment outcomes.MethodsRetrospective study evaluating MINO use in adults at NewYork-Presbyterian Hospital from 2012 to 2017. Patients included received MINO ≥2 days for a culture-positive Gram-negative infection (CDC/NHSN criteria) susceptible to MINO. Patients with MINO started >5 days after positive culture or with untreated polymicrobial infections were excluded. The primary outcome was clinical failure at the end of therapy. Secondary outcomes included 30-day mortality, development of resistance or recurrence within 90 days.Results114 patients were included: majority were male (51%) with median age 57 years. Median duration was 12 days with 8 patients receiving high-dose MINO (≥150 mg q12H). S. maltophilia was the most prevalent pathogen (72%) followed by Klebsiella pneumoniae (16%) with a median MINO MIC of 1 mg/L. 68% of patients received combination therapy. Treatment success was observed in 71 patients (63%). Patients with treatment failure had higher median Charlson Comorbidity Index (5 vs. 3; P = 0.026), SOFA score (7 vs. 5; P = 0.028), and were more likely to have underlying leukemia or lymphoma (39% vs. 7%; P < 0.001). No differences were seen in primary or secondary outcomes between combination and monotherapy regimens. MICs had no impact on failure outcome, 30-day mortality or 90-day recurrence (all P > 0.05); however, MICs ≤ 2 mg/L were associated with increased development of resistance (34% vs. 12%; P = 0.021). In a multivariable analysis, vasopressor use (OR 2.79; 95% CI 1.05,7.41; P = 0.04) and underlying leukemia/lymphoma (OR 4.49; 95% CI 1.26,15.95; P = 0.02) were associated with increased risk of treatment failure.ConclusionMINO MIC impacted resistance, but did not correlate with treatment failure, mortality or recurrence. Severity of illness and comorbidities but not choice of MINO may be associated with clinical failures.Disclosures All authors: No reported disclosures.

Comparison of disaster preparedness between Upstate and Downstate community hospitals in New York.

This study sought to determine whether differences exist in disaster preparedness between Upstate and Downstate community hospitals in New York. A descriptive and analytical cross-sectional survey study was conducted using a 35-element questionnaire. These questions examined six disaster preparedness components: disaster plan development, onsite surge capacity, available materials and resources, disaster education and training, disaster preparedness funding levels, and perception of disaster preparedness. The population surveyed included community hospitals across New York. Invitations to participate in the survey were emailed to the CEOs and disaster preparedness coordinators at 207 of the 208 community hospitals in New York. Eighty hospitals completed surveys, including 41 Upstate hospitals and 39 Downstate facilities. Responses to questions pertaining to the six disaster preparedness elements. There were differences in disaster preparedness between Upstate and Downstate hospitals with respect to disaster plan development, available materials and resources, and disaster education and training. No differences were identified in onsite surge capacity, disaster preparedness funding levels, or perception of disaster preparedness. The results demonstrate the current condition of disaster preparedness in Upstate and Downstate community hospitals in New York. Differences in preparedness between hospitals in the two locations may reflect factors such as availability of resources and differing priorities with regard to threat levels. They also suggest opportunities for improvement in disaster preparedness, which may require additional government resources and advocacy organization efforts.

Endonasal endoscopic transsphenoidal resection of intrinsic third ventricular craniopharyngioma: surgical results.

Intrinsic third ventricular craniopharyngiomas (IVCs) have been reported by some authors to "pose the greatest surgical challenge" of all craniopharyngiomas (CPAs). A variety of open microsurgical approaches have historically been used for resection of these tumors. Despite increased utilization of the endoscopic endonasal approach (EEA) for resection of CPAs in recent years, many authors continue to recommend against use of the EEA for resection of IVCs. In this paper, the authors present the largest series to date utilizing the EEA to remove IVCs. The authors reviewed a prospectively acquired database of the EEA for resection of IVCs over 14 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital. Preoperative MR images were examined independently by two neurosurgeons and a neuroradiologist to identify IVCs. Pre- and postoperative endocrinological, ophthalmological, radiographic, and other morbidities were determined from retrospective chart review and volumetric radiographic analysis. Between January 2006 and August 2017, 10 patients (4 men, 6 women) ranging in age from 26 to 67 years old, underwent resection of an IVC utilizing the EEA. Preoperative endocrinopathy was present in 70% and visual deterioration in 60%. Gross-total resection (GTR) was achieved in 9 (90%) of 10 patients, with achievement of near-total (98%) resection in the remaining patient. Pathology was papillary in 30%. Closure incorporated a "gasket-seal" technique with nasoseptal flap coverage and either lumbar drainage (9 patients) or a ventricular drain (1 patient). Postoperatively, complete anterior and posterior pituitary insufficiency was present in 90% and 70% of patients, respectively. In 4 patients with normal vision prior to surgery, 3 had stable vision following tumor resection. One patient noted a new, incongruous, left inferior homonymous quadrantanopsia postoperatively. In the 6 patients who presented with compromised vision, 2 reported stable vision following surgery. Each of the remaining 4 patients noted significant improvement in vision after tumor resection, with complete restoration of normal vision in 1 patient. Aside from the single case (10%) of visual deterioration referenced above, there were no instances of postoperative neurological decline. Postoperative CSF leakage occurred in 1 morbidly obese patient who required reoperation for revision of closure. After a mean follow-up of 46.8 months (range 4-131 months), tumor recurrence was observed in 2 patients (20%), one of whom was treated with radiation and the other with chemotherapy. Both of these patients had previously undergone GTR of the IVC. The 10 patients described in this report represent the largest number of patients with IVC treated using EEA for resection to date. EEA for resection of IVC is a safe and efficacious operative strategy that should be considered a surgical option in the treatment of this challenging subset of tumors.

Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas.

Gross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur. A retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed. A total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%. While the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.